tci General Surgery Coding Alert - 2019 Issue 2

You Be the Coder: Use Just One Polyp Code

Question: Please help me code this op note: Surgeon resected and retrieved an 8 mm polyp in the descending colon by snare technique. Noting excessive bleeding, the surgeon performed argon-plasma fulguration and placed a hemostatic clip. I’ve been told we should use 45388 for the additional work to stop the bleed. How should we code the case? California Subscriber Answer: You should code the service as 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Despite the documentation of additional work to cauterize the bleed at the site of the excision, you should...

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